Objective: To discuss the technical and anatomical analysis and design of an osteocutaneous allograft transplant incorporating the donor maxilla and the execution of the operative protocol during the transplant. Methods: The Cleveland Clinic reported the world's first successful combined face and maxilla transplant in December 2008. Unlike the 3 prior face transplants, this surgical procedure was done as a salvage operation in a patient who had undergone 23 major reconstructive procedures. The additional complexity due to significant postoperative scarring and recipient vessel depletion presented a unique challenge in this case. The extensive 3-dimensional losses of facial structures in multiple tissue planes required a Le Fort III osteomyocutaneous allotransplant incorporating the donor maxilla. Results: We report the first successful transfer of a complete bony framework and soft-tissue envelope. The allograft has shown excellent integration and no long-term rejection. The traditional conception based on anatomical studies suggested that this transfer would require independent dissection of the internal maxillary vascular system. This was not required in our patient whose allograft was based solely on the facial arterial system and its arcades. Conclusions: Successful near-total face and maxilla allograft transplant can be accomplished based on the facial arterial system and its arcades. This presents a novel method for reconstructing massive facial injuries with significant involvement of the facial skeleton.
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